Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19
Authors: Ashraf Fawzy, Tianshi David Wu, Kunbo Wang, Matthew L. Robinson, Jad Farha, Amanda Bradke, Sherita H. Golden, Yanxun Xu, Brian T. Garibaldi
Journal: JAMA Internal Medicine (2022)

<h3>Importance</h3> Pulse oximetry guides triage and therapy decisions for COVID-19. Whether reported racial inaccuracies in oxygen saturation measured by pulse oximetry are present in patients with COVID-19 and associated with treatment decisions is unknown. <h3>Objective</h3> To determine whether there is differential inaccuracy of pulse oximetry by race or ethnicity among patients with COVID-19 and estimate the association of such inaccuracies with time to recognition of eligibility for oxygen threshold–specific COVID-19 therapies. <h3>Design, Setting, and Participants</h3> This retrospective cohort study of clinical data from 5 referral centers and community hospitals in the Johns Hopkins Health System included patients with COVID-19 who self-identified as Asian, Black, Hispanic, or White. <h3>Exposures</h3> Concurrent measurements (within 10 minutes) of oxygen saturation levels in arterial blood (SaO<sub>2</sub>) and by pulse oximetry (SpO<sub>2</sub>). <h3>Main Outcomes and Measures</h3> For patients with concurrent SpO<sub>2</sub>and SaO<sub>2</sub>measurements, the proportion with occult hypoxemia (SaO<sub>2</sub>&lt;88% with concurrent SpO<sub>2</sub>of 92%-96%) was compared by race and ethnicity, and a covariate-adjusted linear mixed-effects model was produced to estimate the association of race and ethnicity with SpO<sub>2</sub>and SaO<sub>2</sub>difference. This model was applied to identify a separate sample of patients with predicted SaO<sub>2</sub>levels of 94% or less before an SpO<sub>2</sub>level of 94% or less or oxygen treatment initiation. Cox proportional hazards models were used to estimate differences by race and ethnicity in time to recognition of eligibility for guideline-recommended COVID-19 therapies, defined as an SpO<sub>2</sub>level of 94% or less or oxygen treatment initiation. The median delay among individuals who ultimately had recognition of eligibility was then compared. <h3>Results</h3> Of 7126 patients with COVID-19, 1216 patients (63 Asian [5.2%], 478 Black [39.3%], 215 Hispanic [17.7%], and 460 White [37.8%] individuals; 507 women [41.7%]) had 32 282 concurrently measured SpO<sub>2</sub>and SaO<sub>2</sub>. Occult hypoxemia occurred in 19 Asian (30.2%), 136 Black (28.5%), and 64 non-Black Hispanic (29.8%) patients compared with 79 White patients (17.2%). Compared with White patients, SpO<sub>2</sub>overestimated SaO<sub>2</sub>by an average of 1.7% among Asian (95% CI, 0.5%-3.0%), 1.2% among Black (95% CI, 0.6%-1.9%), and 1.1% among non-Black Hispanic patients (95% CI, 0.3%-1.9%). Separately, among 1903 patients with predicted SaO<sub>2</sub>levels of 94% or less before an SpO<sub>2</sub>level of 94% or less or oxygen treatment initiation, compared with White patients, Black patients had a 29% lower hazard (hazard ratio, 0.71; 95% CI, 0.63-0.80), and non-Black Hispanic patients had a 23% lower hazard (hazard ratio, 0.77; 95% CI, 0.66-0.89) of treatment eligibility recognition. A total of 451 patients (23.7%) never had their treatment eligibility recognized, most of whom (247 [54.8%]) were Black. Among the remaining 1452 (76.3%) who had eventual recognition of treatment eligibility, Black patients had a median delay of 1.0 hour (95% CI, 0.23-1.9 hours;<i>P</i> = .01) longer than White patients. There was no significant median difference in delay between individuals of other racial and ethnic minority groups and White patients. <h3>Conclusions and Relevance</h3> The results of this cohort study suggest that racial and ethnic biases in pulse oximetry accuracy were associated with greater occult hypoxemia in Asian, Black, and non-Black Hispanic patients with COVID-19, which was associated with significantly delayed or unrecognized eligibility for COVID-19 therapies among Black and Hispanic patients. This disparity may contribute to worse outcomes among Black and Hispanic patients with COVID-19.